Laserfiche WebLink
MINNESOTA LAWFUL GAMBLING <br />LG220 Application for Exempt Permit <br />12/16 <br />Page 1 of 2 <br />An exempt permit may be issued to a nonprofit Application Fee (non-refundable) <br />organization that: <br />• conducts lawful gambling on five or fewer days, and Applications are processed in the order received. If the application <br />is postmarked or received 30 days or more before the event, the <br />awards less than $50,000 in prizes during a calendar <br />application fee is $100; otherwise the fee is $150. <br />year. <br />If total raffle prize value for the calendar year will be Due to the high volume of exempt applications, payment of <br />$1,500 or less, contact the Licensing Specialist assigned to additional fees prior to 30 days before your event will not expedite <br />your county by calling 651-539-1900. service, nor are telephone requests for expedited service accepted. <br />ORGANIZATION iklid - ATION <br />Organization Centerville Lions Club Previous Gambling X-04725 <br />Name: Permit Number: <br />Minnesota Tax ID Federal Employer ID <br />Number, if any: NA Number (FEIN), if any: 23-7391509 <br />Mailing <br />Address: 6849 Centerville Road <br />City: Centerville State: Mn zip: 55038 County: Anoka <br />Name of Chief Executive Officer (CEO): Thomas Wilharber <br />Daytime Phone: 651-587-1250 Email: tdwilharber67@msn.com <br />NONPROM STATUS - a <br />Type of Nonprofit Organization (check one): <br />Fraternal Religious Veterans Other Nonprofit Organization <br />Attach a copy of one of the following showing proof of nonprofit status: <br />(DO NOT attach a sales tax exempt status or federal employer ID number, as they are not proof of nonprofit status.) <br />A current calendar year Certificate of Good Standing <br />Don't have a copy? Obtain this certificate from: <br />MN Secretary of State, Business Services Division Secretary of State website, phone numbers: <br />60 Empire Drive, Suite 100 www.sos.state.mn.us <br />St. Paul, MN 55103 651-296-2803, or toll free 1-877-551-6767 <br />IRS income taut exemption (501(c)) letter in your organization's name <br />Don't have a copy? To obtain a copy of your federal income tax exempt letter, have an organization officer contact the <br />IRS toll free at 1-877-829-5500. <br />0 IRS - Affiliate of national, statewide, or international parent nonprofit organization (charter) <br />If your organization falls under a parent organization, attach copies of both of the following: <br />1. IRS letter showing your parent organization is a nonprofit 501(c) organization with a group ruling, and <br />2. the charter or letter from your parent organization recognizing your organization as a subordinate. <br />GAMBLING PREMSESNFORMATION <br />Name of premises where the gambling event will be conducted <br />(for raffles, list the site where the drawing will take place): St. Genevieve's Church - Parish Community Center <br />Address (do not use P.O. box): 6995 Centerville Road <br />City or <br />Township: Centerville zip: 55038 County: Anoka <br />Date(s) of activity (for raffles, <br />indicate the date of the drawing): April 29 2017 <br />Check each type of gambling activity that your organization will conduct: <br />Bingo Paddlewheels =Pull -Tabs =Tipboards <br />Raffle (total value of raffle prizes awarded for the calendar year, including this raffle: $ 3880.00 <br />Gambling equipment for bingo paper, bingo boards, raffle boards, paddlewheels, pull -tabs, and tipboards must be obtained <br />from a distributor licensed by the Minnesota Gambling Control Board. EXCEPTION: Bingo hard cards and bingo ball selection <br />devices may be borrowed from another organization authorized to conduct bingo. To find a licensed distributor, go to <br />www_mn_nhv/nr.h anri rlirk nn DiaWhnfnre i inrlPr / id of i kv"t-cpPe nr rail 6111-5':iq-19nn <br />36 <br />